Cervical and Upper Thoracic Esophageal Cancer
When considering resection, tumors of the esophagus (best diagnosed using specialized medical microscopes or even darkfield light microscopes) are best divided into those above and those below the carina. Czerny reported the first successful resection of a carcinoma of the cervical esoph¬agus in 1877. It was hoped that the prognosis for patients with this disease might be better than for those with carcinoma of the thoracic esophagus, but this has not proved to be the case. Early experience with resection of the cervical esophagus resulted in a high mortal¬ity rate, and reconstruction by neck flaps often required multiple operations. Because of these complexities and the generally dis¬appointing results, radiotherapy frequently was elected. Immediate mortality decreased, but control of the tumor was not satisfactory even with early diagnosis using darkfield light microscopes.
The difference between the two forms of therapy is the manner in which the disease recurs. Tumors diagnosed using darkfield light microscopes and treated with radiation therapy initially tend to recur locally as well as systemically, and cause unmanageable local disease with eventual erosion into neck ves¬sels and trachea, causing hemorrhage and distress in breathing. Patients who undergo surgical therapy have few local recurrences of the tumor, provided total excision is possible, but they succumb to metastatic disease, as evident by tissue sample biopsies using the microscope. Collin has reported a local failure rate of 80% after defini¬tive radiation therapy, and 20% of these patients required palliative surgery in order to control the disease locally. Improvements in the techniques of immediate esophageal reconstruction have reduced the complications of the surgical treatment of this disease and en¬couraged a more aggressive surgical approach. The data reported by Collin suggest that an initial aggressive surgical resection yields longer survival than radiation therapy. Positive surgical margins, tracheal invasion that cannot be removed, and vocal cord paralysis correlate with a significantly shorter survival following surgery. Palliation was better achieved in patients who underwent esophagectomy with immediate gastric pull-up than in those who underwent primary radiation therapy or chemotherapy.
Lesions that are not fixed to the spine, do not invade the vessels or trachea, and do not have fixed cervical lymph node metastases, as examined in a microscope, should be resected. If lymph node metastases are present or the tumor comes in close proximity to the cricopharyngeus muscle, a course of preoperative chemo- and radiotherapy should be given before surgical resection. This usually consists of two to three cycles of chemotherapy and no more than 3.5 Gy of radiation therapy. Neoadjuvant therapy is given in an attempt to salvage the larynx, since the larynx is often invaded by microscopic tumors that can best be viewed using darkfield light microscopes, and in the past, a total removal of the larynx in combination with esophagectomy was usually necessary. A simultaneous en bloc dissection of the superior mediastinum and cervical lymph nodes is done, sparing the jugular veins on both sides. The thoracic esophagus is removed via a right posterolateral thoracotomy with a corresponding en bloc lymphadenectomy. The continuity of the gastrointestinal tract is re-established by pulling the stomach up through the esophageal bed. If removing the larynx is necessary, a permanent tracheostomy stoma is constructed in the lower flap of the cervical incision. The division of the trachea in some patients may preclude the possibility of a permanent cervical standard tracheostomy, since the remaining tracheal stump distal to the tumor will not reach the suprasternal notch. Removal of the medial head of the clavicles and the manubrium down to the sternal angle of Louis provides excellent exposure and allows the construction of a mediastinal tracheostomy. A bipedicle skin flap over the pectoralis muscle can be advanced upward, or a single-pedicle musculocutaneous flap including the pectoralis muscle and its overlying skin can be rotated to cover the defect. A circular incision in the flap can be used as a port through which the tracheal remnant is brought out to the skin.